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Valero EG, Acosta Acosta CDP, Vargas Useche W, Orozco Sandoval L, Seija-Butnaru D, Sánchez-Flórez JC, Linares Escobar R, Amaya S. Perioperative Management of Painful Phantom Limb Syndrome: A Narrative Review and Clinical Management Proposal. J Pain Palliat Care Pharmacother 2023:1-15. [PMID: 36929710 DOI: 10.1080/15360288.2023.2187005] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 03/18/2023]
Abstract
Objective: Painful Phantom Limb Syndrome (PPLS) occurs in 50 to 80% of patients undergoing amputation, having a great impact on quality of life, productivity and psychosocial sphere. The objective of this review is to summarize the pharmacological and non-pharmacological strategies, surgical optimization, and provide a multidisciplinary approach aimed at reducing the incidence of chronic pain associated with PPLS in patients undergoing limb amputation.Methods: A narrative review was carried out using Medline, Pubmed, Proquest, LILACS and Cochrane, searching for articles between 2000 and 2021. Articles describing the epidemiology, pathophysiological considerations, and current treatments were selected after a screening process.Results: A multidisciplinary and multimodal approach is required in PPLS, and should include the use of regional techniques, and adjuvants such as NSAIDs, ketamine, lidocaine and gabapentinoids. In addition, an evaluation and continuous management of risk factors for chronic pain in conjunction with the surgical team is necessary.Conclusion: The current literature does not support that a single technique is effective in the prevention of PPLS. However, adequate acute pain control, rehabilitation and early restoration of the body scheme under a multidisciplinary and multimodal approach have shown benefit in the acute setting.
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Hunt W, Nath M, Bowrey S, Colvin L, Thompson JP. Effect of a continuous perineural levobupivacaine infusion on pain after major lower limb amputation: a randomised double-blind placebo-controlled trial. BMJ Open 2023; 13:e060349. [PMID: 36764711 PMCID: PMC9923266 DOI: 10.1136/bmjopen-2021-060349] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/12/2023] Open
Abstract
OBJECTIVES Randomised controlled trial of the effect of a perineural infusion of levobupivacaine on moderate/severe phantom limb pain 6 months after major lower limb amputation. SETTING Single-centre, UK university hospital. PARTICIPANTS Ninety patients undergoing above-knee and below-knee amputation for chronic limb threatening ischaemia under general anaesthesia. Exclusion criteria were patients having surgery under neuraxial anaesthesia; inability to operate a patient-controlled analgesia device or complete a Visual Analogue Scale; amputation for trauma or malignancy; or contraindication to levobupivacaine. INTERVENTIONS Either levobupivacaine 0.125% or saline 0.9% (10 mL bolus, infusion of 8 mL/hour for 96 hours) via a sciatic or posterior tibial nerve sheath catheter placed under direct vision during surgery. PRIMARY AND SECONDARY OUTCOME MEASURES The primary outcome measure was the presence of phantom limb pain, residual limb pain and phantom limb sensations up to 6 months after amputation. Secondary outcome measures included early postoperative pain and morphine requirements after surgery. RESULTS Data from 81 participants were analysed; 6-month follow-up data were available for 62 patients. Pain and morphine requirements varied widely before and after amputation in both groups. The incidences of moderate/severe phantom limb pain, residual limb pain and phantom limb sensations were low from 6 weeks with no significant differences between groups in phantom limb pain at rest (OR 0.56, 95% CI 0.14 to 2.14, p=0.394) or movement (OR 0.58, 95% CI 0.15 to 2.21, p=0.425) at 6 months. Early postoperative pain scores were low in both groups with no between-group differences in residual limb pain or phantom limb sensations (rest or movement) at any time point. High postoperative morphine consumption was associated with worsening phantom limb pain both at rest (-17.51, 95% CI -24.29 to -10.74; p<0.001) and on movement (-18.54, 95% CI -25.58 to -11.49; p<0.001). The incidence of adverse effects related to the study was low in both groups: postoperative nausea, vomiting and sedation scores were similar, and there were no features of local anaesthetic toxicity. CONCLUSIONS Long-term phantom limb pain, residual limb pain and phantom limb sensations were not reduced significantly by perineural infusion of levobupivacaine, although the study was underpowered to show significant differences in the primary outcome. The incidence of phantom limb pain was lower than previously reported, possibly attributable to frequent assessment and early intervention to identify and treat postoperative pain when it occurred. There were large variations in postoperative pain scores, high requirements for analgesics before and after surgery and some problems maintaining recruitment and long -term follow-up. Knowledge of these potential problems should inform future research in this group of patients. Further work should investigate the association between perioperative morphine requirements and late phantom limb pain. TRIAL REGISTRATION NUMBERS EudraCT 2007-000619-27; ISRCTN68691928.
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Affiliation(s)
- William Hunt
- Division of Anaesthesia Critical Care & Pain Management, Department of Cardiovascular Sciences, University of Leicester, Leicester, UK
| | - Mintu Nath
- Division of Anaesthesia Critical Care & Pain Management, Department of Cardiovascular Sciences, University of Leicester, Leicester, UK
- Medical Statistics Team, University of Aberdeen, Aberdeen, UK
| | - Sarah Bowrey
- Division of Anaesthesia Critical Care & Pain Management, Department of Cardiovascular Sciences, University of Leicester, Leicester, UK
- Anaesthesia Critical Care and Pain Management, Leicester Royal Infirmary, University Hospitals of Leicester NHS Trust, Leicester, UK
| | - Lesley Colvin
- Division of Population Health and Genomics, University of Dundee, Dundee, UK
| | - Jonathan P Thompson
- Division of Anaesthesia Critical Care & Pain Management, Department of Cardiovascular Sciences, University of Leicester, Leicester, UK
- Anaesthesia Critical Care and Pain Management, Leicester Royal Infirmary, University Hospitals of Leicester NHS Trust, Leicester, UK
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Zagorulko OI, Medvedeva LA. [Treatment and prevention phantom pain syndrome in mine-explosive injuries]. Khirurgiia (Mosk) 2023:83-88. [PMID: 38088844 DOI: 10.17116/hirurgia202312183] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/18/2023]
Abstract
Phantom pain syndrome significantly impairs the quality of life and effectiveness of surgical treatment after limb amputations. The authors consider possible strategies for treatment and prevention in elective surgical intervention and mine-explosive injuries.
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Affiliation(s)
- O I Zagorulko
- Petrovsky National Research Center of Surgery, Moscow, Russian Federation
| | - L A Medvedeva
- Petrovsky National Research Center of Surgery, Moscow, Russian Federation
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Evans AG, Chaker SC, Curran GE, Downer MA, Assi PE, Joseph JT, Kassis SA, Thayer WP. Postamputation Residual Limb Pain Severity and Prevalence: A Systematic Review and Meta-Analysis. Plast Surg (Oakv) 2022; 30:254-268. [PMID: 35990396 PMCID: PMC9389065 DOI: 10.1177/22925503211019646] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/05/2021] [Accepted: 04/15/2021] [Indexed: 08/03/2023] Open
Abstract
Background: Individuals with an extremity amputation are predisposed to persistent pain that reduces their quality of life. Residual limb pain is defined as pain that is felt in the limb after amputation. Methods: A Preferred Reporting Items for Systematic Reviews and Meta-Analyses-compliant systematic review of 5 databases from inception to June 2020 was performed and is registered under the PROSPERO ID: CRD42020199297. Included studies were clinical trials with residual limb pain assessed at a minimum follow-up of 1 week. Meta-analyses of residual limb pain prevalence and severity were performed with subgroups of extremity and amputation etiology. Results: Twenty clinical trials met criteria and reported on a total of 1347 patients. Mean patient ages ranged from 38 to 77. Residual limb pain prevalence at 1 week, 1 month, 3 months, 6 months, 1 year, and 2 years, respectively, was 50%, 11%, 23%, 27%, 22%, and 24%. Mean residual limb pain severity at the 6 months or longer follow-up was 4.19 out of 10 for cancer amputations, 2.70 for traumatic amputations, 0.47 for vasculopathy amputations, 1.01 for lower extremity amputations, and 3.56 for upper extremity amputations. Conclusions: Residual limb pain severity varies according to the etiology of amputation and is more common after upper extremity amputation than lower extremity amputations. The most severe pain is reported by patients undergoing amputations due to cancer, followed by traumatic amputations, while vascular amputation patients report lower pain severity. Promising methods of reducing long-term pain are preoperative pain control, nerve or epidural blocks, use of memantine, calcitonin-containing blocks, and prophylactic nerve coaptations.
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Affiliation(s)
- Adam G. Evans
- School of Medicine, Meharry Medical College, Nashville, TN,
USA
| | | | | | | | - Patrick E. Assi
- Department of Plastic Surgery, Vanderbilt University Medical Center,
Nashville, TN, USA
| | - Jeremy T. Joseph
- Department of Plastic Surgery, Vanderbilt University Medical Center,
Nashville, TN, USA
| | - Salam Al Kassis
- Department of Plastic Surgery, Vanderbilt University Medical Center,
Nashville, TN, USA
| | - Wesley P. Thayer
- Department of Plastic Surgery, Vanderbilt University Medical Center,
Nashville, TN, USA
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5
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Klinisches Update zu Phantomschmerz. Schmerz 2022; 37:195-214. [DOI: 10.1007/s00482-022-00629-x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 02/02/2022] [Indexed: 10/18/2022]
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Al-Hassani A, Wahlen BM, Ayasa MAM, Hakim S, Khoschnau S, El-Menyar A, Al-Thani H. OUP accepted manuscript. J Surg Case Rep 2022; 2022:rjac001. [PMID: 35169435 PMCID: PMC8840889 DOI: 10.1093/jscr/rjac001] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/14/2021] [Accepted: 01/02/2022] [Indexed: 11/13/2022] Open
Abstract
Among the work-related injuries, meat grinder injuries are not uncommon. One of the major challenges in the trauma resuscitation room is the appropriate choice of anesthesia/analgesia when the patient is still conscious and the second challenge is to find the best way to early extract the patient’s limb out of the machine without adding more suffering. Herein, we presented a 23-year-old male patient who was brought fully conscious in a kneeling position with the right forearm entrapped in a big meat grinder machine with part of the crushed fingers being extruded out of the machine. The patient was in severe pain; however, his vital signs were stable. Analgo-sedation with Midazolam/Ketamine followed by ultrasound guided upper limb regional anesthesia was used and showed to be a fast and safe alternative in a conscious, not fasting patient when the extremity is still entrapped in a meat grinder machine.
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Affiliation(s)
- Ammar Al-Hassani
- Department of Surgery, Trauma Surgery, Hamad Medical Corporation, Doha, Qatar
| | - Bianca M Wahlen
- Department of Anesthesiology, Hamad Medical Corporation, Doha, Qatar
| | | | - Suhail Hakim
- Department of Surgery, Trauma Surgery, Hamad Medical Corporation, Doha, Qatar
| | - Sherwan Khoschnau
- Department of Surgery, Trauma Surgery, Hamad Medical Corporation, Doha, Qatar
| | - Ayman El-Menyar
- Correspondence address. Department of Surgery, Trauma and Vascular Surgery, and Clinical Research, Hamad General Hospital and Weill Cornell Medical School, P. O Box 3050, Doha, Qatar. Fax: +974-44394031; E-mail:
| | - Hassan Al-Thani
- Department of Surgery, Trauma and Vascular Surgery, Hamad Medical Corporation, Doha, Qatar
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Jafra A, Makkar J, Bandyopadhay A, Jain K, Gopinathan N, Singh P. Effect of perioperative sciatic nerve block on chronic pain in patients undergoing below-knee amputation: A randomised controlled trial. Indian J Anaesth 2022; 66:S300-S306. [DOI: 10.4103/ija.ija_796_21] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/27/2021] [Revised: 09/07/2022] [Accepted: 09/09/2022] [Indexed: 11/07/2022] Open
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Benedetti MG, De Santis L, Mariani G, Donati D, Bardelli R, Perrone M, Brunelli S. Chronic pain in lower limb amputees: Is there a correlation with the use of perioperative epidural or perineural analgesia? NeuroRehabilitation 2021; 49:129-138. [PMID: 34180426 DOI: 10.3233/nre-210077] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/21/2022]
Abstract
BACKGROUND Chronic pain is common in patients who undergo lower limb amputation. The use of epidural or perineural catheters seems to reduce acute pain after surgery but their effects in a longer follow up are unknown. OBJECTIVE To evaluate the long-term prevalence of phantom limb sensation (PLS), phantom limb pain (PLP), and residual limb pain (RLP) and their correlation with perioperative use of epidural or perineural catheters. METHODS Postal survey. Patients with trans-femoral, trans-tibial or hemi-pelvectomy amputation were asked to partake in the study. The Prosthetic Evaluation Questionnaire was used for the presence of chronic post-surgical pain. Use of catheters was retrieved from medical notes. RESULTS 57 patients at a mean of 4.4 years follow up were included. PLS was reported in 68.4%, PLP in 63.2 % and RLP in 54.4% of amputees. No correlation was identified between pain syndromes and the presence of individual catheters and the duration of their permanence. The simultaneous use of 2 catheters was related to a lesser presence of PLP. CONCLUSIONS Data on prevalence of PLP, PLS and RLP are consistent with the literature. Favourable effects in PLP reduction in the long term follow up was related to the simultaneous use of two catheters.
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Affiliation(s)
- Maria Grazia Benedetti
- Physical Therapy and Rehabilitation Unit, University of Bologna - IRCCS-Istituto Ortopedico Rizzoli, Bologna, Italy
| | - Letizia De Santis
- Physical Therapy and Rehabilitation Unit, University of Bologna - IRCCS-Istituto Ortopedico Rizzoli, Bologna, Italy
| | - Giorgio Mariani
- Physical Medicine and Rehabilitation Unit -IRCCS -Istituto Ortopedico Rizzoli, Bologna, BO, Italy
| | - Danilo Donati
- Physical Therapy and Rehabilitation Unit, University of Bologna - IRCCS-Istituto Ortopedico Rizzoli, Bologna, Italy
| | - Roberta Bardelli
- Physical Medicine and Rehabilitation Unit -IRCCS -Istituto Ortopedico Rizzoli, Bologna, BO, Italy
| | - Mariada Perrone
- Anesthesia and Post-Operative Intensive Care, IRCCS-Istituto ortopedico Rizzoli, Bologna, BO, Italy
| | - Stefano Brunelli
- Fondazione Santa Lucia, Scientific Institute for Research, Hospitalization and Health Care, Rome, Italy
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Laloo R, Ambler GK, Locker D, Twine CP, Bosanquet DC. Systematic Review and Meta-Analysis of the Effect of Perineural Catheters in Major Lower Limb Amputations. Eur J Vasc Endovasc Surg 2021; 62:295-303. [PMID: 34088614 DOI: 10.1016/j.ejvs.2021.03.008] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/13/2020] [Revised: 02/23/2021] [Accepted: 03/06/2021] [Indexed: 11/17/2022]
Abstract
OBJECTIVE Controlling pain after major lower limb amputation (MLLA) is of critical importance to patients and clinicians. The aim of this systematic review and meta-analysis was to assess the effect of perineural catheters (PNCs) on post-operative pain, post-operative morphine requirement, in-hospital mortality, long term phantom limb pain, and chronic stump pain. METHODS A systematic review using PubMed, EMBASE via OVID and the Cochrane library from database inception (1946) to 20 October 2020 was performed according to PRISMA guidelines. Studies involving patients undergoing MLLA which reported on post-operative morphine requirement, pain scores, in-hospital mortality, phantom limb pain (PLP), and chronic stump pain were included. Studies comparing PNC use with epidural or wound site local anaesthetic infusions were excluded. Outcome data were extracted from individual studies and meta-analysis was performed using a random effects (Mantel-Haenszel) model for dichotomous data using an odds ratio (OR) summary statistic with 95% confidence intervals (CI), and with an inverse variance random effects model for continuous data using a standardised mean difference (SMD) summary statistic with 95% CIs. Sensitivity analyses were performed for post-operative pain scores and post-operative morphine requirement. Study quality was assessed using the Downs and Black score, and outcomes were assessed using the GRADE tool. RESULTS Ten studies reporting on 731 patients were included, with 350 patients receiving a PNC and 381 receiving standard care. PNC use is associated with a reduction in post-operative pain (SMD -0.30, 95% CI -0.58 - -0.01, p = .040, I2 = 54%, GRADE quality of evidence: low) and post-operative morphine requirements (SMD -0.63, 95% CI -1.03 - -0.23, p = .002, I2 = 75%, GRADE quality of evidence: moderate), although the effect of PNC on reduced post-operative morphine requirements is lost on sensitivity analysis of randomised trials only (p = .40). No demonstrable effect was found on in-hospital mortality, PLP, or chronic stump pain (GRADE quality of evidence: low). CONCLUSION PNC use in amputees is associated with a significant reduction in post-operative pain scores and post-operative morphine requirements, although this latter finding is lost on sensitivity analysis of randomised trials only.
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Affiliation(s)
- Ryan Laloo
- Department of Vascular Surgery, Leeds Teaching Hospitals Trust, United Kingdom
| | - Graeme K Ambler
- Bristol Centre for Surgical Research, University of Bristol, Bristol, United Kingdom; North Bristol NHS Trust, Southmead Hospital, Bristol, United Kingdom
| | - Dafydd Locker
- Department of Vascular Surgery, Royal Gwent Hospital, Newport, United Kingdom
| | - Christopher P Twine
- Bristol Centre for Surgical Research, University of Bristol, Bristol, United Kingdom; North Bristol NHS Trust, Southmead Hospital, Bristol, United Kingdom
| | - David C Bosanquet
- Department of Vascular Surgery, Royal Gwent Hospital, Newport, United Kingdom.
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Doshi TL, Dworkin RH, Polomano RC, Carr DB, Edwards RR, Finnerup NB, Freeman RL, Paice JA, Weisman SJ, Raja SN. AAAPT Diagnostic Criteria for Acute Neuropathic Pain. PAIN MEDICINE 2021; 22:616-636. [PMID: 33575803 DOI: 10.1093/pm/pnaa407] [Citation(s) in RCA: 10] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 12/31/2022]
Abstract
OBJECTIVE Acute neuropathic pain is a significant diagnostic challenge, and it is closely related to our understanding of both acute pain and neuropathic pain. Diagnostic criteria for acute neuropathic pain should reflect our mechanistic understanding and provide a framework for research on and treatment of these complex pain conditions. METHODS The Analgesic, Anesthetic, and Addiction Clinical Trial Translations, Innovations, Opportunities, and Networks (ACTTION) public-private partnership with the U.S. Food and Drug Administration (FDA), the American Pain Society (APS), and the American Academy of Pain Medicine (AAPM) collaborated to develop the ACTTION-APS-AAPM Pain Taxonomy (AAAPT) for acute pain. A working group of experts in research and clinical management of neuropathic pain was convened. Group members used literature review and expert opinion to develop diagnostic criteria for acute neuropathic pain, as well as three specific examples of acute neuropathic pain conditions, using the five dimensions of the AAAPT classification of acute pain. RESULTS AAAPT diagnostic criteria for acute neuropathic pain are presented. Application of these criteria to three specific conditions (pain related to herpes zoster, chemotherapy, and limb amputation) illustrates the spectrum of acute neuropathic pain and highlights unique features of each condition. CONCLUSIONS The proposed AAAPT diagnostic criteria for acute neuropathic pain can be applied to various acute neuropathic pain conditions. Both the general and condition-specific criteria may guide future research, assessment, and management of acute neuropathic pain.
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Affiliation(s)
- Tina L Doshi
- Department of Anesthesiology and Critical Care Medicine, Division of Pain Medicine, Johns Hopkins University, Baltimore, Maryland, USA
| | - Robert H Dworkin
- Department of Anesthesiology, University of Rochester School of Medicine and Dentistry, Rochester, New York, and Department of Neurology, Center for Human Experimental Therapeutics, University of Rochester School of Medicine and Dentistry, Rochester, New York, USA
| | - Rosemary C Polomano
- Division of Biobehavioral Health Sciences, University of Pennsylvania-School of Nursing, Philadelphia, Pennsylvania, USA
| | - Daniel B Carr
- Public Health and Community Medicine Program, Tufts University School of Medicine, Boston, Massachusetts, USA
| | - Robert R Edwards
- Department of Anesthesiology, Perioperative, and Pain Medicine, Brigham and Women's Hospital, Boston, Massachusetts, USA
| | - Nanna B Finnerup
- Danish Pain Research Center, Department of Clinical Medicine, Aarhus University, and Department of Neurology, Aarhus University Hospital, Aarhus, Denmark
| | - Roy L Freeman
- Center for Autonomic and Peripheral Nerve Disorders, Beth Israel Deaconess Medical Center, Boston, Massachusetts, USA
| | - Judith A Paice
- Cancer Pain Program, Northwestern University, Feinberg School of Medicine, Chicago, Illinois, USA
| | - Steven J Weisman
- Jane B. Pettit Pain and Headache Center, Children's Wisconsin, Departments of Anesthesiology and Pediatrics, Medical College of Wisconsin, Milwaukee, Wisconsin, USA
| | - Srinivasa N Raja
- Department of Anesthesiology and Critical Care Medicine, Division of Pain Medicine, Johns Hopkins University, Baltimore, Maryland, USA
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Surgical prevention of terminal neuroma and phantom limb pain: a literature review. Arch Plast Surg 2021; 48:310-322. [PMID: 34024077 PMCID: PMC8143949 DOI: 10.5999/aps.2020.02180] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/27/2020] [Accepted: 02/08/2021] [Indexed: 12/02/2022] Open
Abstract
The incidence of extremity amputation is estimated at about 200,000 cases annually. Over 25% of patients suffer from terminal neuroma or phantom limb pain (TNPLP), resulting in pain, inability to wear a prosthetic device, and lost work. Once TNPLP develops, there is no definitive cure. Therefore, there has been an emerging focus on TNPLP prevention. We examined the current literature on TNPLP prevention in patients undergoing extremity amputation. A literature review was performed using Ovid Medline, Cochrane Collaboration Library, and Google Scholar to identify all original studies that addressed surgical prophylaxis against TNPLP. The search was conducted using both Medical Subject Headings and free-text using the terms “phantom limb pain,” “amputation neuroma,” and “surgical prevention of amputation neuroma.” Fifteen studies met the inclusion criteria, including six prospective trials, two comprehensive literature reviews, four retrospective chart reviews, and three case series/technique reviews. Five techniques were identified, and each was incorporated into a target-based classification system. A small but growing body of literature exists regarding the surgical prevention of TNPLP. Targeted muscle reinnervation (TMR), a form of physiologic target reassignment, has the greatest momentum in the academic surgical community, with multiple recent prospective studies demonstrating superior prevention of TNPLP. Neurorrhaphy and transposition with implantation are supported by less robust evidence, but merit future study as alternatives to TMR.
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Prevalence of postamputation pain and its subtypes: a meta-analysis with meta-regression. Pain Rep 2021; 6:e918. [PMID: 33981935 PMCID: PMC8108594 DOI: 10.1097/pr9.0000000000000918] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/20/2020] [Revised: 02/03/2021] [Accepted: 02/16/2021] [Indexed: 12/29/2022] Open
Abstract
Introduction The inconsistent use of standardized approaches for classifying postamputation pain (PAP) has been a barrier to establishing its prevalence. Objectives The primary objective of this systematic review and meta-analysis is to determine the prevalence of nontraumatic lower-extremity PAP using an established taxonomy. The secondary objective is to determine the prevalence of PAP subtypes, including phantom limb pain and residual limb pain (RLP). Methods An a priori protocol was registered, and a database search was conducted by a reference librarian. Randomized trials and uncontrolled studies were eligible for inclusion. The risk of bias was assessed using a tool developed for uncontrolled studies. A total of 2679 studies were screened, and 13 studies met inclusion criteria (n = 1063). Results The sources of risk of bias included selection bias and, to a lesser extent, whether the outcome was adequately ascertained. Two studies reported the prevalence of PAP and the pooled prevalence was 61% (95% confidence interval [CI], 33%-86%) with high heterogeneity (I2 = 93%). Thirteen studies reported the prevalence of phantom limb pain and the pooled prevalence was 53% (95% CI, 40%-66%) with high heterogeneity (I2 = 93%). Eight studies reported the prevalence of RLP and the pooled prevalence was 32% (95% CI 24%-41%) with high heterogeneity (I2 = 76%). Clinical subtypes of RLP were not reported. Conclusions The prevalence of PAP is high in patients with nontraumatic lower-extremity amputations. Ongoing research that uses a taxonomy for PAP is needed to fully delineate the prevalence of PAP subtypes.
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Fatima H, Chaudhary O, Krumm S, Mufarrih SH, Mahmood F, Pannu A, Sharkey A, Baribeau V, Qureshi N, Polshin V, Bose R, Hamdan AD, Schermerhorn ML, Matyal R. Enhanced Post-Operative Recovery with Continuous Peripheral Nerve Block After Lower Extremity Amputation. Ann Vasc Surg 2021; 76:399-405. [PMID: 33895258 DOI: 10.1016/j.avsg.2021.03.029] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/10/2020] [Revised: 03/26/2021] [Accepted: 03/27/2021] [Indexed: 11/19/2022]
Abstract
BACKGROUND Despite progress in perioperative care standards, there has not been a significant risk reduction in morbidity and mortality rates of lower extremity amputations, an intermediate risk surgery performed on high risk patients. The single-shot peripheral nerve block has shown equivocal impact on postoperative course following lower extremity amputation. Hence, we assessed the potential of preemptive use of continuous catheter-based peripheral nerve block in lower extremity amputations for reduction in pulmonary complications, acute post-operative pain scores, and opioid use in post-operative period. METHODS A retrospective review of a quality improvement project initiated in 2018 was conducted to compare outcomes amongst general anesthesia in combination with a catheter-based peripheral nerve block (catheter group) and general anesthesia alone in patients receiving lower extremity amputation. The rate of postoperative pulmonary complications was identified as a primary endpoint. The secondary outcomes assessed were acute post-operative pain scores and opioid consumption up to 48 hours. Our analysis was adjusted for potential confounding variables inclusive of demographics, medical comorbidities, type of surgical procedure and smoking status. RESULTS Ninety-six patients were included in the study (61 in the general anesthesia group, 35 in the catheter group). After adjusting for baseline demographics, comorbidities, surgical technique and smoking status, the odds of postoperative pulmonary complications were significantly lower with catheter-based peripheral nerve block in comparison to general anesthesia alone, OR 0.11 [95% CI, 0.01- 0.88] (P = 0.048). The decrease in acute pain scores was also observed in the catheter group when compared to general anesthesia alone, OR 0.72 [95% CI, 0.56 - 0.93] (P = 0.012). Similarly, the opioid consumption was also lower in the catheter group in comparison to general anesthesia alone, OR 0.97 [95% CI, 0.95 - 0.99] (P = 0.025). CONCLUSION Preemptive use of continuous peripheral nerve block in patients undergoing lower extremity amputation reduces the incidence of pulmonary complications, acute postoperative pain scores and narcotic use in post-operative period.
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Affiliation(s)
- Huma Fatima
- Department of Anesthesia, Critical Care and Pain Medicine, Beth Israel Deaconess Medical Centre, Harvard Medical School, Boston, MA, USA
| | - Omar Chaudhary
- Department of Anesthesia, Critical Care and Pain Medicine, Beth Israel Deaconess Medical Centre, Harvard Medical School, Boston, MA, USA
| | - Santiago Krumm
- Department of Anesthesia, Critical Care and Pain Medicine, Beth Israel Deaconess Medical Centre, Harvard Medical School, Boston, MA, USA
| | - Syed Hamza Mufarrih
- Department of Anesthesia, Critical Care and Pain Medicine, Beth Israel Deaconess Medical Centre, Harvard Medical School, Boston, MA, USA
| | - Feroze Mahmood
- Department of Anesthesia, Critical Care and Pain Medicine, Beth Israel Deaconess Medical Centre, Harvard Medical School, Boston, MA, USA
| | - Ameeka Pannu
- Department of Anesthesia, Critical Care and Pain Medicine, Beth Israel Deaconess Medical Centre, Harvard Medical School, Boston, MA, USA
| | - Aidan Sharkey
- Department of Anesthesia, Critical Care and Pain Medicine, Beth Israel Deaconess Medical Centre, Harvard Medical School, Boston, MA, USA
| | - Vincent Baribeau
- Department of Anesthesia, Critical Care and Pain Medicine, Beth Israel Deaconess Medical Centre, Harvard Medical School, Boston, MA, USA
| | - Nada Qureshi
- Department of Anesthesia, Critical Care and Pain Medicine, Beth Israel Deaconess Medical Centre, Harvard Medical School, Boston, MA, USA
| | - Victor Polshin
- Department of Anesthesia, Critical Care and Pain Medicine, Beth Israel Deaconess Medical Centre, Harvard Medical School, Boston, MA, USA
| | - Ruma Bose
- Department of Anesthesia, Critical Care and Pain Medicine, Beth Israel Deaconess Medical Centre, Harvard Medical School, Boston, MA, USA
| | - Allen D Hamdan
- Department of Vascular and Endovascular Surgery, Cardiovascular Institute, Beth Israel Deaconess Medical Center, Harvard Medical School
| | - Marc L Schermerhorn
- Department of Vascular and Endovascular Surgery, Cardiovascular Institute, Beth Israel Deaconess Medical Center, Harvard Medical School
| | - Robina Matyal
- Department of Anesthesia, Critical Care and Pain Medicine, Beth Israel Deaconess Medical Centre, Harvard Medical School, Boston, MA, USA.
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Ilfeld BM, Khatibi B, Maheshwari K, Madison SJ, Esa WAS, Mariano ER, Kent ML, Hanling S, Sessler DI, Eisenach JC, Cohen SP, Mascha EJ, Ma C, Padwal JA, Turan A. Ambulatory continuous peripheral nerve blocks to treat postamputation phantom limb pain: a multicenter, randomized, quadruple-masked, placebo-controlled clinical trial. Pain 2021; 162:938-955. [PMID: 33021563 PMCID: PMC7920494 DOI: 10.1097/j.pain.0000000000002087] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/18/2020] [Revised: 09/15/2020] [Accepted: 09/17/2020] [Indexed: 01/13/2023]
Abstract
Phantom limb pain is thought to be sustained by reentrant neural pathways, which provoke dysfunctional reorganization in the somatosensory cortex. We hypothesized that disrupting reentrant pathways with a 6-day-long continuous peripheral nerve block reduces phantom pain 4 weeks after treatment. We enrolled patients who had an upper- or lower-limb amputation and established phantom pain. Each was randomized to receive a 6-day perineural infusion of either ropivacaine or normal saline. The primary outcome was the average phantom pain severity as measured with a Numeric Rating Scale (0-10) at 4 weeks, after which an optional crossover treatment was offered within the following 0 to 12 weeks. Pretreatment pain scores were similar in both groups, with a median (interquartile range) of 5.0 (4.0, 7.0) for each. After 4 weeks, average phantom limb pain intensity was a mean (SD) of 3.0 (2.9) in patients given local anesthetic vs 4.5 (2.6) in those given placebo (difference [95% confidence interval] 1.3 [0.4, 2.2], P = 0.003). Patients given local anesthetic had improved global impression of change and less pain-induced physical and emotional dysfunction, but did not differ on depression scores. For subjects who received only the first infusion (no self-selected crossover), the median decrease in phantom limb pain at 6 months for treated subjects was 3.0 (0, 5.0) vs 1.5 (0, 5.0) for the placebo group; there seemed to be little residual benefit at 12 months. We conclude that a 6-day continuous peripheral nerve block reduces phantom limb pain as well as physical and emotional dysfunction for at least 1 month.
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Affiliation(s)
- Brian M. Ilfeld
- Department of Anesthesiology, University of California San Diego, San Diego, CA, United States
- Outcomes Research Consortium, Cleveland, OH, United States
| | - Bahareh Khatibi
- Department of Anesthesiology, University of California San Diego, San Diego, CA, United States
| | - Kamal Maheshwari
- Outcomes Research Consortium, Cleveland, OH, United States
- Departments of General Anesthesia and Outcomes Research, the Cleveland Clinic, Cleveland, OH, United States
| | - Sarah J. Madison
- Department of Anesthesiology, University of California San Diego, San Diego, CA, United States
| | - Wael Ali Sakr Esa
- Outcomes Research Consortium, Cleveland, OH, United States
- Departments of General Anesthesia and Outcomes Research, the Cleveland Clinic, Cleveland, OH, United States
| | - Edward R. Mariano
- Department of Anesthesiology, Perioperative and Pain Medicine, Palo Alto Veterans Affairs, Palo Alto, CA, United States
| | - Michael L. Kent
- Department of Anesthesiology, Walter Reed National Military Medical Center, Bethesda, MD, United States
| | - Steven Hanling
- Department of Anesthesiology, Naval Medical Center San Diego, San Diego, CA, United States
| | - Daniel I. Sessler
- Outcomes Research Consortium, Cleveland, OH, United States
- Department of Outcomes Research, the Cleveland Clinic, Cleveland, OH, United States
| | - James C. Eisenach
- Outcomes Research Consortium, Cleveland, OH, United States
- Department of Anesthesiology, Wake Forest School of Medicine, Winston-Salem, NC, United States
| | - Steven P. Cohen
- Department of Anesthesiology, Johns Hopkins, Baltimore, MD, United States
| | - Edward J. Mascha
- Outcomes Research Consortium, Cleveland, OH, United States
- Departments of Quantitative Health Sciences and Outcomes Research, the Cleveland Clinic, Cleveland, OH, United States
| | - Chao Ma
- Departments of Quantitative Health Sciences and Outcomes Research, the Cleveland Clinic, Cleveland, OH, United States
| | - Jennifer A. Padwal
- Department of Radiology, University of California San Diego, San Diego, CA, United States
- Department of Radiology, Stanford University, Stanford, CA, United States
| | - Alparslan Turan
- Outcomes Research Consortium, Cleveland, OH, United States
- Departments of General Anesthesia and Outcomes Research, the Cleveland Clinic, Cleveland, OH, United States
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16
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Abstract
Phantom limb pain is highly prevalent after amputation. Treatment results will probably benefit from an interdisciplinary team and individually adapted surgical, prosthetic and pain medicine approaches. Introduction: Most patients with amputation (up to 80%) suffer from phantom limb pain postsurgery. These are often multimorbid patients who also have multiple risk factors for the development of chronic pain from a pain medicine perspective. Surgical removal of the body part and sectioning of peripheral nerves result in a lack of afferent feedback, followed by neuroplastic changes in the sensorimotor cortex. The experience of severe pain, peripheral, spinal, and cortical sensitization mechanisms, and changes in the body scheme contribute to chronic phantom limb pain. Psychosocial factors may also affect the course and the severity of the pain. Modern amputation medicine is an interdisciplinary responsibility. Methods: This review aims to provide an interdisciplinary overview of recent evidence-based and clinical knowledge. Results: The scientific evidence for best practice is weak and contrasted by various clinical reports describing the polypragmatic use of drugs and interventional techniques. Approaches to restore the body scheme and integration of sensorimotor input are of importance. Modern techniques, including apps and virtual reality, offer an exciting supplement to already established approaches based on mirror therapy. Targeted prosthesis care helps to obtain or restore limb function and at the same time plays an important role reshaping the body scheme. Discussion: Consequent prevention and treatment of severe postoperative pain and early integration of pharmacological and nonpharmacological interventions are required to reduce severe phantom limb pain. To obtain or restore body function, foresighted surgical planning and technique as well as an appropriate interdisciplinary management is needed.
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17
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Dumitrascu CI, Warner NS, Stewart TM, Amundson AW, Bruns DL, Hanson AC, Schulte PJ, Smith MM, Brown MJ, Niesen AD, Mantilla CB, Warner MA. Peripheral Nerve Blockade with Combined Standard and Liposomal Bupivacaine in Major Lower-Extremity Amputation. Pain Pract 2020; 21:299-307. [PMID: 33058387 DOI: 10.1111/papr.12959] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/17/2020] [Revised: 09/22/2020] [Accepted: 09/28/2020] [Indexed: 11/26/2022]
Abstract
BACKGROUND AND OBJECTIVES Optimizing perioperative analgesia for patients undergoing major lower-extremity amputation remains a considerable challenge. The utility of liposomal bupivacaine as a component of peripheral nerve blockade for lower-extremity amputation is unknown. METHODS We conducted an observational study comparing three different perioperative analgesic techniques for adults undergoing major lower-extremity amputation under general anesthesia between 2012 and 2017 at an academic medical center: (1) no regional anesthesia, (2) peripheral nerve blockade with standard bupivacaine, and (3) peripheral nerve blockade with a mixture of standard and liposomal bupivacaine. The primary outcome of cumulative opioid oral morphine milligram equivalent utilization in the first 72 hours postoperatively was compared across groups utilizing multivariable linear regression. RESULTS A total of 631 unique anesthetics were included for 578 unique patients, including 416 (66%) without regional anesthesia, 131 (21%) with peripheral nerve blockade with a mixture of standard and liposomal bupivacaine, and 84 (13%) with peripheral nerve blockade with standard bupivacaine alone. Cumulative morphine equivalents were lower in those receiving peripheral nerve blockade with combined standard and liposomal bupivacaine compared with those not receiving regional anesthesia (multiplicative increase 0.67; 95% CI 0.50 to 0.90; P = 0.007). There were no significant differences in opioid utilization between peripheral nerve blockade groups (P = 0.59). CONCLUSIONS Peripheral nerve blockade is associated with reduced opioid requirements after lower-extremity amputation compared with general anesthesia alone. However, the incorporation of liposomal bupivacaine is not significantly different to blockade employing only standard bupivacaine.
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Affiliation(s)
- Catalina I Dumitrascu
- Department of Anesthesiology & Perioperative Medicine, Mayo Clinic, Rochester, Minnesota, U.S.A
| | - Nafisseh S Warner
- Department of Anesthesiology & Perioperative Medicine, Mayo Clinic, Rochester, Minnesota, U.S.A.,Division of Pain Medicine, Mayo Clinic, Rochester, Minnesota, U.S.A
| | - Thomas M Stewart
- Department of Anesthesiology & Perioperative Medicine, Mayo Clinic, Rochester, Minnesota, U.S.A
| | - Adam W Amundson
- Department of Anesthesiology & Perioperative Medicine, Mayo Clinic, Rochester, Minnesota, U.S.A
| | - Danette L Bruns
- Anesthesia Clinical Research Unit, Mayo Clinic, Rochester, Minnesota, U.S.A
| | - Andrew C Hanson
- Division of Biomedical Statistics, Mayo Clinic, Rochester, Minnesota, U.S.A
| | - Phillip J Schulte
- Division of Biomedical Statistics, Mayo Clinic, Rochester, Minnesota, U.S.A
| | - Mark M Smith
- Department of Anesthesiology & Perioperative Medicine, Mayo Clinic, Rochester, Minnesota, U.S.A
| | - Michael J Brown
- Department of Anesthesiology & Perioperative Medicine, Mayo Clinic, Rochester, Minnesota, U.S.A
| | - Adam D Niesen
- Department of Anesthesiology & Perioperative Medicine, Mayo Clinic, Rochester, Minnesota, U.S.A
| | - Carlos B Mantilla
- Department of Anesthesiology & Perioperative Medicine, Mayo Clinic, Rochester, Minnesota, U.S.A
| | - Matthew A Warner
- Department of Anesthesiology & Perioperative Medicine, Mayo Clinic, Rochester, Minnesota, U.S.A.,Division of Critical Care Medicine, Mayo Clinic, Rochester, Minnesota, U.S.A
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Alexander JH, Jordan SW, West JM, Compston A, Fugitt J, Bowen JB, Dumanian GA, Pollock R, Mayerson JL, Scharschmidt TJ, Valerio IL. Targeted muscle reinnervation in oncologic amputees: Early experience of a novel institutional protocol. J Surg Oncol 2019; 120:348-358. [PMID: 31197851 DOI: 10.1002/jso.25586] [Citation(s) in RCA: 64] [Impact Index Per Article: 12.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/14/2019] [Revised: 05/14/2019] [Accepted: 05/25/2019] [Indexed: 12/17/2022]
Abstract
BACKGROUND We describe a multidisciplinary approach for comprehensive care of amputees with concurrent targeted muscle reinnervation (TMR) at the time of amputation. METHODS Our TMR cohort was compared to a cross-sectional sample of unselected oncologic amputees not treated at our institution (N = 58). Patient-Reported Outcomes Measurement Information System (NRS, PROMIS) were used to assess postamputation pain. RESULTS Thirty-one patients underwent amputation with concurrent TMR during the study; 27 patients completed pain surveys; 15 had greater than 1 year follow-up (mean follow-up 14.7 months). Neuroma symptoms occurred significantly less frequently and with less intensity among the TMR cohort. Mean differences for PROMIS pain intensity, behavior, and interference for phantom limb pain (PLP) were 5.855 (95%CI 1.159-10.55; P = .015), 5.896 (95%CI 0.492-11.30; P = .033), and 7.435 (95%CI 1.797-13.07; P = .011) respectively, with lower scores for TMR cohort. For residual limb pain, PROMIS pain intensity, behavior, and interference mean differences were 5.477 (95%CI 0.528-10.42; P = .031), 6.195 (95%CI 0.705-11.69; P = .028), and 6.816 (95%CI 1.438-12.2; P = .014), respectively. Fifty-six percent took opioids before amputation compared to 22% at 1 year postoperatively. CONCLUSIONS Multidisciplinary care of amputees including concurrent amputation and TMR, multimodal postoperative pain management, amputee-centered rehabilitation, and peer support demonstrates reduced incidence and severity of neuroma and PLP.
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Affiliation(s)
- John H Alexander
- Department of Orthopaedics, The Ohio State University James Wexner Medical Center, Columbus, Ohio
| | - Sumanas W Jordan
- Division of Plastic Surgery, Northwestern University Feinberg School of Medicine, Chicago, Illinois
| | - Julie M West
- Department of Plastic Surgery, The Ohio State University Wexner Medical Center, Columbus, Ohio
| | - Amy Compston
- Department of Oncologic Rehabilitation, The Ohio State University James Comprehensive Cancer Center, Columbus, Ohio
| | - Jennifer Fugitt
- Division of Plastic Surgery, Northwestern University Feinberg School of Medicine, Chicago, Illinois
| | - J Byers Bowen
- Department of Plastic Surgery, The Ohio State University Wexner Medical Center, Columbus, Ohio
| | - Gregory A Dumanian
- Division of Plastic Surgery, Northwestern University Feinberg School of Medicine, Chicago, Illinois
| | - Raphael Pollock
- Division of Surgical Oncology, The Ohio State University Wexner Medical Center, Columbus, Ohio
| | - Joel L Mayerson
- Department of Orthopaedics, The Ohio State University James Wexner Medical Center, Columbus, Ohio
| | - Thomas J Scharschmidt
- Department of Orthopaedics, The Ohio State University James Wexner Medical Center, Columbus, Ohio
| | - Ian L Valerio
- Department of Plastic Surgery, The Ohio State University Wexner Medical Center, Columbus, Ohio
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19
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Grap SM, Fox E, Freeman M, Blackall GF, Dalal PG. Acute Postoperative Pain Management After Major Limb Amputation in a Pediatric Patient: A Case Report. J Perianesth Nurs 2019; 34:801-809. [PMID: 30745262 DOI: 10.1016/j.jopan.2018.11.004] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/21/2017] [Revised: 11/06/2018] [Accepted: 11/14/2018] [Indexed: 01/21/2023]
Abstract
PURPOSE Although total prevention of phantom pain is difficult, pediatric patients requiring amputation benefit from an individualized combination of analgesic techniques for phantom pain reduction using a multimodal and interprofessional approach. This is especially useful in the event a single therapy is ineffective for total pain reduction, and may ultimately lead to a reduction in chronic pain development. DESIGN Case report with multimodal and interprofessional approach. METHODS A 16-year-old patient with synovial sarcoma underwent a right hemipelvectomy and hip disarticulation. The patient had significant preoperative cancer pain requiring high-dose opioid analgesics prior to surgery. An interprofessional multimodal pain management strategy was used for acute and long-term reduction of postoperative phantom pain. FINDINGS Although our patient developed acute phantom pain, multimodal therapy reduced immediate pain with resolution by 2 years follow-up. CONCLUSIONS An individualized plan using interprofessional teamwork before surgery may provide optimal results in alleviating phantom pain after amputation for pediatric patients.
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20
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Factors affecting phantom limb pain in patients undergoing amputation: retrospective study. J Anesth 2019; 33:216-220. [PMID: 30603827 DOI: 10.1007/s00540-018-2599-0] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/05/2018] [Accepted: 12/15/2018] [Indexed: 01/19/2023]
Abstract
PURPOSE The efficacy of preemptive analgesia for prevention of phantom limb pain has been controversial although pain management before amputation is empirically important. The aim of this study was to determine the associated factors with perioperative phantom limb pain. METHODS Following approval by the Medical Ethics Committee in our university, medical records of patients receiving limb amputation surgery in our hospital between April 1, 2013 and October 31, 2017 were retrospectively reviewed. To determine which pre-operative factors could affect the development of phantom limb pain, we performed univariate analysis to find candidate factors (p < 0.05), and then did multivariate regression analysis. RESULTS Incidence of phantom limb pain was 50% (22/44). There was no difference between the groups in types of anesthesia and post-operative pain levels. The multivariate logistic regression including possible confounders suggested that diabetes mellitus and uncontrollable preoperative pain with non-steroidal anti-inflammatory drugs (NSAIDs) were independently associated with the development of phantom limb pain (Adjusted odds ratio (OR) 0.238 [95% confidential interval (CI) 0.0643-0.883], p = 0.032, Adjusted OR 6.360 [95% CI 1.280-31.50], p = 0.024, respectively). CONCLUSION The types of anesthesia and the degree of postoperative pain were not related to the development of phantom limb pain. The present data suggest that insufficient preoperative pain with NSAIDs and diabetes mellitus would give an impact on the development of phantom limb pain.
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Abstract
OBJECTIVE To review the literature related to different treatment strategies for the general population of individuals with amputation, spinal cord injury, and cerebral palsy, as well as how this may impact pain management in a correlated athlete population. DATA SOURCES A comprehensive literature search was performed linking pain with terms related to different impairment types. MAIN RESULTS There is a paucity in the literature relating to treatment of pain in athletes with impairment; however, it is possible that the treatment strategies used in the general population of individuals with impairment may be translated to the athlete population. There are a wide variety of treatment options including both pharmacological and nonpharmacological treatments which may be applicable in the athlete. CONCLUSIONS It is the role of the physician to determine which strategy of the possible treatment options will best facilitate the management of pain in the individual athlete in a sport-specific setting.
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22
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Weinstein EJ, Levene JL, Cohen MS, Andreae DA, Chao JY, Johnson M, Hall CB, Andreae MH. Local anaesthetics and regional anaesthesia versus conventional analgesia for preventing persistent postoperative pain in adults and children. Cochrane Database Syst Rev 2018; 6:CD007105. [PMID: 29926477 PMCID: PMC6377212 DOI: 10.1002/14651858.cd007105.pub4] [Citation(s) in RCA: 39] [Impact Index Per Article: 6.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/01/2023]
Abstract
BACKGROUND Regional anaesthesia may reduce the rate of persistent postoperative pain (PPP), a frequent and debilitating condition. This review was originally published in 2012 and updated in 2017. OBJECTIVES To compare local anaesthetics and regional anaesthesia versus conventional analgesia for the prevention of PPP beyond three months in adults and children undergoing elective surgery. SEARCH METHODS We searched CENTRAL, MEDLINE, and Embase to December 2016 without any language restriction. We used a combination of free text search and controlled vocabulary search. We limited results to randomized controlled trials (RCTs). We updated this search in December 2017, but these results have not yet been incorporated in the review. We conducted a handsearch in reference lists of included studies, review articles and conference abstracts. We searched the PROSPERO systematic review registry for related systematic reviews. SELECTION CRITERIA We included RCTs comparing local or regional anaesthesia versus conventional analgesia with a pain outcome beyond three months after elective, non-orthopaedic surgery. DATA COLLECTION AND ANALYSIS At least two review authors independently assessed trial quality and extracted data and adverse events. We contacted study authors for additional information. We presented outcomes as pooled odds ratios (OR) with 95% confidence intervals (95% CI), based on random-effects models (inverse variance method). We analysed studies separately by surgical intervention, but pooled outcomes reported at different follow-up intervals. We compared our results to Bayesian and classical (frequentist) models. We investigated heterogeneity. We assessed the quality of evidence with GRADE. MAIN RESULTS In this updated review, we identified 40 new RCTs and seven ongoing studies. In total, we included 63 RCTs in the review, but we were only able to synthesize data on regional anaesthesia for the prevention of PPP beyond three months after surgery from 39 studies, enrolling a total of 3027 participants in our inclusive analysis.Evidence synthesis of seven RCTs favoured epidural anaesthesia for thoracotomy, suggesting the odds of having PPP three to 18 months following an epidural for thoracotomy were 0.52 compared to not having an epidural (OR 0.52 (95% CI 0.32 to 0.84, 499 participants, moderate-quality evidence). Simlarly, evidence synthesis of 18 RCTs favoured regional anaesthesia for the prevention of persistent pain three to 12 months after breast cancer surgery with an OR of 0.43 (95% CI 0.28 to 0.68, 1297 participants, low-quality evidence). Pooling data at three to 8 months after surgery from four RCTs favoured regional anaesthesia after caesarean section with an OR of 0.46, (95% CI 0.28 to 0.78; 551 participants, moderate-quality evidence). Evidence synthesis of three RCTs investigating continuous infusion with local anaesthetic for the prevention of PPP three to 55 months after iliac crest bone graft harvesting (ICBG) was inconclusive (OR 0.20, 95% CI 0.04 to 1.09; 123 participants, low-quality evidence). However, evidence synthesis of two RCTs also favoured the infusion of intravenous local anaesthetics for the prevention of PPP three to six months after breast cancer surgery with an OR of 0.24 (95% CI 0.08 to 0.69, 97 participants, moderate-quality evidence).We did not synthesize evidence for the surgical subgroups of limb amputation, hernia repair, cardiac surgery and laparotomy. We could not pool evidence for adverse effects because the included studies did not examine them systematically, and reported them sparsely. Clinical heterogeneity, attrition and sparse outcome data hampered evidence synthesis. High risk of bias from missing data and lack of blinding across a number of included studies reduced our confidence in the findings. Thus results must be interpreted with caution. AUTHORS' CONCLUSIONS We conclude that there is moderate-quality evidence that regional anaesthesia may reduce the risk of developing PPP after three to 18 months after thoracotomy and three to 12 months after caesarean section. There is low-quality evidence that regional anaesthesia may reduce the risk of developing PPP three to 12 months after breast cancer surgery. There is moderate evidence that intravenous infusion of local anaesthetics may reduce the risk of developing PPP three to six months after breast cancer surgery.Our conclusions are considerably weakened by the small size and number of studies, by performance bias, null bias, attrition and missing data. Larger, high-quality studies, including children, are needed. We caution that except for breast surgery, our evidence synthesis is based on only a few small studies. On a cautionary note, we cannot extend our conclusions to other surgical interventions or regional anaesthesia techniques, for example we cannot conclude that paravertebral block reduces the risk of PPP after thoracotomy. There are seven ongoing studies and 12 studies awaiting classification that may change the conclusions of the current review once they are published and incorporated.
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Affiliation(s)
- Erica J Weinstein
- Albert Einstein College of Medicine of Yeshiva University1300 Morris Park AveBronxNYUSA10461
| | - Jacob L Levene
- Albert Einstein College of Medicine of Yeshiva University1300 Morris Park AveBronxNYUSA10461
| | - Marc S Cohen
- Montefiore Medical Center, Albert Einstein College of MedicineDepartment of Anesthesiology111 E 210 StreetBronxNYUSA#N4‐005
| | - Doerthe A Andreae
- Milton S Hershey Medical CenterDepartment of Allergy/ Immunology500 University DrHersheyPAUSA17033
| | - Jerry Y Chao
- Montefiore Medical Center, Albert Einstein College of MedicineDepartment of Anesthesiology111 E 210 StreetBronxNYUSA#N4‐005
| | - Matthew Johnson
- Teachers College, Columbia UniversityHuman DevelopmentNew YorkNYUSA10027
| | - Charles B Hall
- Albert Einstein College of MedicineDivision of Biostatistics, Department of Epidemiology and Population Health1300 Morris Park AvenueBronxNYUSA10461
| | - Michael H Andreae
- Milton S Hershey Medical CentreDepartment of Anesthesiology & Perioperative Medicine500 University DriveH187HersheyPAUSA17033
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23
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Weinstein EJ, Levene JL, Cohen MS, Andreae DA, Chao JY, Johnson M, Hall CB, Andreae MH. Local anaesthetics and regional anaesthesia versus conventional analgesia for preventing persistent postoperative pain in adults and children. Cochrane Database Syst Rev 2018; 4:CD007105. [PMID: 29694674 PMCID: PMC6080861 DOI: 10.1002/14651858.cd007105.pub3] [Citation(s) in RCA: 27] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/09/2023]
Abstract
BACKGROUND Regional anaesthesia may reduce the rate of persistent postoperative pain (PPP), a frequent and debilitating condition. This review was originally published in 2012 and updated in 2017. OBJECTIVES To compare local anaesthetics and regional anaesthesia versus conventional analgesia for the prevention of PPP beyond three months in adults and children undergoing elective surgery. SEARCH METHODS We searched CENTRAL, MEDLINE, and Embase to December 2016 without any language restriction. We used a combination of free text search and controlled vocabulary search. We limited results to randomized controlled trials (RCTs). We updated this search in December 2017, but these results have not yet been incorporated in the review. We conducted a handsearch in reference lists of included studies, review articles and conference abstracts. We searched the PROSPERO systematic review registry for related systematic reviews. SELECTION CRITERIA We included RCTs comparing local or regional anaesthesia versus conventional analgesia with a pain outcome beyond three months after elective, non-orthopaedic surgery. DATA COLLECTION AND ANALYSIS At least two review authors independently assessed trial quality and extracted data and adverse events. We contacted study authors for additional information. We presented outcomes as pooled odds ratios (OR) with 95% confidence intervals (95% CI), based on random-effects models (inverse variance method). We analysed studies separately by surgical intervention, but pooled outcomes reported at different follow-up intervals. We compared our results to Bayesian and classical (frequentist) models. We investigated heterogeneity. We assessed the quality of evidence with GRADE. MAIN RESULTS In this updated review, we identified 40 new RCTs and seven ongoing studies. In total, we included 63 RCTs in the review, but we were only able to synthesize data on regional anaesthesia for the prevention of PPP beyond three months after surgery from 41 studies, enrolling a total of 3143 participants in our inclusive analysis.Evidence synthesis of seven RCTs favoured epidural anaesthesia for thoracotomy, suggesting the odds of having PPP three to 18 months following an epidural for thoracotomy were 0.52 compared to not having an epidural (OR 0.52 (95% CI 0.32 to 0.84, 499 participants, moderate-quality evidence). Simlarly, evidence synthesis of 18 RCTs favoured regional anaesthesia for the prevention of persistent pain three to 12 months after breast cancer surgery with an OR of 0.43 (95% CI 0.28 to 0.68, 1297 participants, low-quality evidence). Pooling data at three to 8 months after surgery from four RCTs favoured regional anaesthesia after caesarean section with an OR of 0.46, (95% CI 0.28 to 0.78; 551 participants, moderate-quality evidence). Evidence synthesis of three RCTs investigating continuous infusion with local anaesthetic for the prevention of PPP three to 55 months after iliac crest bone graft harvesting (ICBG) was inconclusive (OR 0.20, 95% CI 0.04 to 1.09; 123 participants, low-quality evidence). However, evidence synthesis of two RCTs also favoured the infusion of intravenous local anaesthetics for the prevention of PPP three to six months after breast cancer surgery with an OR of 0.24 (95% CI 0.08 to 0.69, 97 participants, moderate-quality evidence).We did not synthesize evidence for the surgical subgroups of limb amputation, hernia repair, cardiac surgery and laparotomy. We could not pool evidence for adverse effects because the included studies did not examine them systematically, and reported them sparsely. Clinical heterogeneity, attrition and sparse outcome data hampered evidence synthesis. High risk of bias from missing data and lack of blinding across a number of included studies reduced our confidence in the findings. Thus results must be interpreted with caution. AUTHORS' CONCLUSIONS We conclude that there is moderate-quality evidence that regional anaesthesia may reduce the risk of developing PPP after three to 18 months after thoracotomy and three to 12 months after caesarean section. There is low-quality evidence that regional anaesthesia may reduce the risk of developing PPP three to 12 months after breast cancer surgery. There is moderate evidence that intravenous infusion of local anaesthetics may reduce the risk of developing PPP three to six months after breast cancer surgery.Our conclusions are considerably weakened by the small size and number of studies, by performance bias, null bias, attrition and missing data. Larger, high-quality studies, including children, are needed. We caution that except for breast surgery, our evidence synthesis is based on only a few small studies. On a cautionary note, we cannot extend our conclusions to other surgical interventions or regional anaesthesia techniques, for example we cannot conclude that paravertebral block reduces the risk of PPP after thoracotomy. There are seven ongoing studies and 12 studies awaiting classification that may change the conclusions of the current review once they are published and incorporated.
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Affiliation(s)
- Erica J Weinstein
- Albert Einstein College of Medicine of Yeshiva University1300 Morris Park AveBronxUSA10461
| | - Jacob L Levene
- Albert Einstein College of Medicine of Yeshiva University1300 Morris Park AveBronxUSA10461
| | - Marc S Cohen
- Montefiore Medical Center, Albert Einstein College of MedicineDepartment of Anesthesiology111 E 210 StreetBronxUSA#N4‐005
| | - Doerthe A Andreae
- Milton S Hershey Medical CenterDepartment of Allergy/ Immunology500 University DrHersheyUSA17033
| | - Jerry Y Chao
- Montefiore Medical Center, Albert Einstein College of MedicineDepartment of Anesthesiology111 E 210 StreetBronxUSA#N4‐005
| | - Matthew Johnson
- Teachers College, Columbia UniversityHuman DevelopmentNew YorkUSA10027
| | - Charles B Hall
- Albert Einstein College of MedicineDivision of Biostatistics, Department of Epidemiology and Population Health1300 Morris Park AvenueBronxUSA10461
| | - Michael H Andreae
- Milton S Hershey Medical CentreDepartment of Anesthesiology & Perioperative Medicine500 University DriveH187HersheyUSA17033
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Ahuja V, Thapa D, Ghai B. Strategies for prevention of lower limb post-amputation pain: A clinical narrative review. J Anaesthesiol Clin Pharmacol 2018; 34:439-449. [PMID: 30774224 PMCID: PMC6360885 DOI: 10.4103/joacp.joacp_126_17] [Citation(s) in RCA: 15] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/30/2022] Open
Abstract
Postamputation limb pain or phantom limb pain (PLP) develops due to the complex interplay of peripheral and central sensitization. The pain mechanisms are different during the initial phase following amputation as compared with the chronic PLP. The literature describes extensively about the management of established PLP, which may not be applicable as a preventive strategy for PLP. The novelty of the current narrative review is that it focuses on the preventive strategies of PLP. The institution of preoperative epidural catheter prior to amputation and its continuation in the immediate postoperative period reduced perioperative opioid consumption (Level II). Optimized preoperative epidural or intravenous patient-controlled analgesia starting 48 hours and continuing for 48 hours postoperatively decreased PLP at 6 months (Level II). Preventive role of epidural LA with ketamine (Level II) reduced persistent pain at 1 year and LA with calcitonin decreased PLP at 12 months (Level II). Peripheral nerve catheters have opioid sparing effect in the immediate postoperative period in postamputation patients (Level I), but evidence is low for the prevention of PLP (Level III). Gabapentin did not reduce the incidence or intensity of postamputation pain (Level II). The review in related context mentions evidence regarding therapeutic role of gabapentanoids, peripheral nerve catheters, and psychological therapy in established PLP. In future, randomized controlled trials with long-term follow-up of patients receiving epidural analgesia, perioperative peripheral nerve catheters, oral gabapentanoids, IV ketamine, or mechanism-based modality for prevention of PLP as primary outcome are required.
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Affiliation(s)
- Vanita Ahuja
- Department of Anaesthesia and Intensive Care, Government Medical College and Hospital, Chandigarh, India
| | - Deepak Thapa
- Department of Anaesthesia and Intensive Care, Government Medical College and Hospital, Chandigarh, India
| | - Babita Ghai
- Department of Anaesthesia and Intensive Care, Postgraduate Institute of Medical Education and Research, Chandigarh, India
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Bosanquet DC, Ambler GK, Waldron CA, Thomas-Jones E, Brookes-Howell L, Kelson M, Pickles T, Harris D, Fitzsimmons D, Saxena N, Twine CP. Perineural local anaesthetic catheter after major lower limb amputation trial (PLACEMENT): study protocol for a randomised controlled pilot study. Trials 2017; 18:629. [PMID: 29284534 PMCID: PMC5747086 DOI: 10.1186/s13063-017-2357-x] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/16/2017] [Accepted: 11/27/2017] [Indexed: 12/03/2022] Open
Abstract
Background Pain after major lower limb amputation for peripheral arterial disease (PAD) is a significant problem. A perineural catheter (PNC) can be placed adjacent to the major nerve at the time of amputation with a continuous local anaesthetic infusion given postoperatively to try and reduce pain. Although low-quality observational data suggest that PNC usage reduces postoperative opioid requirements, there are limited data regarding its effect on pain. The aim of PLACEMENT is to explore the feasibility of running an effectiveness trial to assess the impact of a PNC with continuous local anaesthetic infusion, inserted at the time of amputation, on short and medium-term postoperative outcomes. Methods/design Fifty patients undergoing a major lower limb amputation (below or above the knee) for PAD will be recruited from two centres. Patients will be randomised in a 1:1 ratio to receive standard postoperative analgesia, with or without insertion of a PNC and local anaesthetic infusion for the first 5 postoperative days. Outcome data will be captured for the first 5 days, including pain scores (primary outcome, captured three times a day), opioid use, nausea or vomiting, itching, dizziness and complications. Patients will be contacted 2 and 6 months after surgery to assess quality of life, phantom limb pain, chronic stump pain and total healthcare costs. Semi-structured interviews will be conducted with at least 10 patients (dependent on saturation of analytic themes on preliminary coding) purposefully sampled to achieve variation in site and study arm. Interviews will explore patients’ perception of post-amputation pain and its treatment, and experience of study processes. Semi-structured interviews with 5–10 health professionals will explore feasibility, fidelity, and acceptability of the study. Data from this pilot will be used to assess feasibility of, and estimate parameters to calculate the sample size for an effectiveness trial. Full ethical approval has been granted (Wales Research Ethics Committee 3 reference number 16/WA/0353). Discussion PLACEMENT will be the first study to explore the feasibility of running an effectiveness trial on PNC usage for postoperative pain in amputees, and provide parameters to calculate the appropriate sample size for this study. Trial registration ISRCTN.com, ISRCTN85710690. Registered on 21 October 2016. European Clinical Trials Database (EudraCT), 2016-003544-37. Registered on 24 August 2016. Electronic supplementary material The online version of this article (doi:10.1186/s13063-017-2357-x) contains supplementary material, which is available to authorized users.
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Affiliation(s)
- David C Bosanquet
- Aneurin Bevan University Health Board, Royal Gwent Hospital, Cardiff Road, Newport, NP16 2UB, UK
| | - Graeme K Ambler
- Aneurin Bevan University Health Board, Royal Gwent Hospital, Cardiff Road, Newport, NP16 2UB, UK.,Division of Population Medicine, Cardiff University, 5th Floor, Neuadd Meirionnydd, Heath Park, Cardiff, CF14 4XW, UK
| | - Cherry-Ann Waldron
- Centre for Trials Research, Cardiff University, 7th Floor, Neuadd Meirionnydd, Heath Park, Cardiff, CF14 4XW, UK
| | - Emma Thomas-Jones
- Centre for Trials Research, Cardiff University, 7th Floor, Neuadd Meirionnydd, Heath Park, Cardiff, CF14 4XW, UK
| | - Lucy Brookes-Howell
- Centre for Trials Research, Cardiff University, 7th Floor, Neuadd Meirionnydd, Heath Park, Cardiff, CF14 4XW, UK
| | - Mark Kelson
- Centre for Trials Research, Cardiff University, 7th Floor, Neuadd Meirionnydd, Heath Park, Cardiff, CF14 4XW, UK
| | - Tim Pickles
- Centre for Trials Research, Cardiff University, 7th Floor, Neuadd Meirionnydd, Heath Park, Cardiff, CF14 4XW, UK
| | - Debbie Harris
- Centre for Trials Research, Cardiff University, 7th Floor, Neuadd Meirionnydd, Heath Park, Cardiff, CF14 4XW, UK
| | - Deborah Fitzsimmons
- Swansea Centre for Health Economics, College of Human Health Sciences, Swansea University, Singleton Park, Swansea, SA2 8PP, UK
| | - Neeraj Saxena
- Department of Anaesthetics, Royal Glamorgan Hospital, Cwm Taf Local Health Board, Llantrisant, UK.,School of Psychology, Cardiff University, Cardiff, CF10 3AX, UK.,Psychology and Therapeutic Studies, University of South Wales, Pontypridd, CF37 1DL, UK
| | - Christopher P Twine
- Aneurin Bevan University Health Board, Royal Gwent Hospital, Cardiff Road, Newport, NP16 2UB, UK. .,Division of Population Medicine, Cardiff University, 5th Floor, Neuadd Meirionnydd, Heath Park, Cardiff, CF14 4XW, UK.
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Kent ML, Hsia HLJ, Van de Ven TJ, Buchheit TE. Perioperative Pain Management Strategies for Amputation: A Topical Review. PAIN MEDICINE 2017; 18:504-519. [PMID: 27402960 DOI: 10.1093/pm/pnw110] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 01/15/2023]
Abstract
Objective To review acute pain management strategies in patients undergoing amputation with consideration of preoperative patient factors, pharmacologic/interventional modalities, and multidisciplinary care models to alleviate suffering in the immediate post-amputation setting. Background Regardless of surgical indication, patients undergoing amputation suffer from significant residual limb pain and phantom limb pain in the acute postoperative phase. Most studies have primarily focused on strategies to prevent persistent pain with inclusion of immediate postoperative outcomes as secondary measures. Pharmacologic agents, including gabapentin, ketamine, and calcitonin, and interventional modalities such as neuraxial and perineural catheters, have been examined in the perioperative period. Design Focused Literature Review. Results Pharmacologic agents (gabapentin, ketamine, calcitonin) have not shown consistent efficacy. Neuraxial analgesia has demonstrated both an opioid sparing and analgesic benefit while results have been mixed regarding perineural catheters in the immediate post-amputation setting. However, several early studies of perineural catheters employed sub-optimal techniques (distal surgical placement), and prolonged use of perineural catheters may provide a sustained benefit. Regardless of analgesic technique, a multidisciplinary approach is necessary for optimal care. Conclusion Patient-tailored analgesic regimens utilizing catheter-based techniques are essential in the acute post-amputation phase and should be implemented in all patients undergoing amputation. Future research should focus on improved measurement of acute pain and comparisons of effective analgesic regimens instead of single techniques.
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Affiliation(s)
- Michael L Kent
- Department of Anesthesiology, Walter Reed National Military Medical Center, Uniformed Services University of the Health Sciences, Bethesda, Maryland, USA
| | - Hung-Lun John Hsia
- Department of Anesthesiology, Duke University Medical Center, Durham VA Medical Center, Durham, North Carolina, USA
| | - Thomas J Van de Ven
- Department of Anesthesiology, Duke University Medical Center, Durham VA Medical Center, Durham, North Carolina, USA
| | - Thomas E Buchheit
- Department of Anesthesiology, Duke University Medical Center, Durham VA Medical Center, Durham, North Carolina, USA
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Yin Y, Zhang L, Xiao H, Wen CB, Dai YE, Yang G, Zuo YX, Liu J. The pre-amputation pain and the postoperative deafferentation are the risk factors of phantom limb pain: a clinical survey in a sample of Chinese population. BMC Anesthesiol 2017; 17:69. [PMID: 28549447 PMCID: PMC5446733 DOI: 10.1186/s12871-017-0359-6] [Citation(s) in RCA: 20] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/13/2017] [Accepted: 05/14/2017] [Indexed: 02/05/2023] Open
Abstract
BACKGROUND To provide an overview of phantom limb pain (PLP) in China. This includes the prevalence of PLP and possible risk factors. METHODS In a retrospective study, telephone interviews were conducted with 391 amputation patients who underwent extremity amputations at a tertiary hospital in China. RESULTS PLP was found in 29% of the amputees. Pre-amputation pain (OR = 10.4, P = 0.002) and postoperative analgesia (OR = 4.9, P = 0.008) were identified as high-risk factors for PLP. 82.1% of PLP patients experienced pre-amputation pain. The average pain intensity of PLP was 5.1 ± 2.2, with 31.9% having severe intensity. The effects of PLP on the quality of the PLP patients were as follows: 7.8% of the patients had to limit their daily life and 29.0% of the patients had to limit their social activities. 17.3 and 25.7% of patients experienced depression and sleeping disorder respectively, while 18.9% had loss of interest and even 16.1% of PLP patients had attempted suicide. No effective treatments were found in 78.9% of these patients. CONCLUSIONS PLP has markedly affected the lives of patients. Pre-amputation pain and postoperative epidural analgesia might be risk factors for the phantom limb pain after amputation. Prevention of pre-amputation pain and sudden post-amputation deafferentation should be recommended to the amputees.
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Affiliation(s)
- Yan Yin
- Department of Pain management, West China Hospital, Sichuan University, Chengdu, Sichuan, 610041, People's Republic of China
| | - Lan Zhang
- Department of Anesthesiology, Sichuan Orthopedics Hospital, Chengdu, Sichuan, 610041, China
| | - Hong Xiao
- Department of Pain management, West China Hospital, Sichuan University, Chengdu, Sichuan, 610041, People's Republic of China.
| | - Chuan-Bing Wen
- Department of Anesthesiology, Sichuan Academy of Medical Sciences & Sichuan provincial People's Hospital, Chengdu, Sichuan, 610000, China
| | - Yue-E Dai
- Department of Anesthesiology, Sichuan Academy of Medical Sciences & Sichuan provincial People's Hospital, Chengdu, Sichuan, 610000, China
| | - Guang Yang
- Department of Anesthesiology, Sichuan Orthopedics Hospital, Chengdu, Sichuan, 610041, China
| | - Yun-Xia Zuo
- Department of Anesthesiology, West China Hospital, Sichuan University, Chengdu, Sichuan, 610041, China
| | - Jin Liu
- Department of Anesthesiology, West China Hospital, Sichuan University, Chengdu, Sichuan, 610041, China
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Ahmed A, Bhatnagar S, Mishra S, Khurana D, Joshi S, Ahmad SM. Prevalence of Phantom Limb Pain, Stump Pain, and Phantom Limb Sensation among the Amputated Cancer Patients in India: A Prospective, Observational Study. Indian J Palliat Care 2017; 23:24-35. [PMID: 28216859 PMCID: PMC5294433 DOI: 10.4103/0973-1075.197944] [Citation(s) in RCA: 30] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2022] Open
Abstract
INTRODUCTION The phantom limb pain (PLP) and phantom limb sensation (PLS) are very common among amputated cancer patients, and they lead to considerable morbidity. In spite of this, there is a lack of epidemiological data of this phenomenon among the Asian population. This study was done to provide the data from Indian population. METHODS The prevalence of PLP, stump pain (SP), and PLS was prospectively analyzed from the amputated cancer patients over a period of 2 years in Dr. B.R.A. Institute Rotary Cancer Hospital, All India Institute of Medical Sciences, New Delhi. The risk factors and the impact of phantom phenomenon on patients were also noted. RESULTS The prevalence of PLP was 41% at 3 and 12 months and 45.3% at 6 months, whereas that of SP and PLS was 14.4% and 71.2% at 3 months, 18.75% and 37.1% at 6 months, 15.8% and 32.4% at 12 months, respectively. There was higher prevalence of PLP and PLS among the patients with history of preamputation pain, smoking with proximal level of amputation, receiving general anesthesia, receiving intravenous (IV) opioid postoperative analgesia, and developing neuroma or infection. CONCLUSION The prevalence of PLP and PLS was higher among the cancer amputees as compared to SP, and a few risk factors responsible for their higher prevalence were found in our study. The PLP and PLS lead to considerable morbidity in terms of sleep disturbance and depression.
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Affiliation(s)
- Arif Ahmed
- Department of Anesthesia, Pain and Palliative Care, Dr. B.R.A. Institute Rotary Cancer Hospital, All Institute of Medical Sciences, New Delhi, India
| | - Sushma Bhatnagar
- Department of Anesthesia, Pain and Palliative Care, Dr. B.R.A. Institute Rotary Cancer Hospital, All Institute of Medical Sciences, New Delhi, India
| | - Seema Mishra
- Department of Anesthesia, Pain and Palliative Care, Dr. B.R.A. Institute Rotary Cancer Hospital, All Institute of Medical Sciences, New Delhi, India
| | - Deepa Khurana
- Department of Anesthesia, Pain and Palliative Care, Dr. B.R.A. Institute Rotary Cancer Hospital, All Institute of Medical Sciences, New Delhi, India
| | - Saurabh Joshi
- Department of Anesthesia, Pain and Palliative Care, Dr. B.R.A. Institute Rotary Cancer Hospital, All Institute of Medical Sciences, New Delhi, India
| | - Syed Mehmood Ahmad
- Department of Anesthesia, Pain and Palliative Care, Dr. B.R.A. Institute Rotary Cancer Hospital, All Institute of Medical Sciences, New Delhi, India
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Preoperative state anxiety, acute postoperative pain, and analgesic use in persons undergoing lower limb amputation. Clin J Pain 2016; 31:699-706. [PMID: 26153780 DOI: 10.1097/ajp.0000000000000150] [Citation(s) in RCA: 29] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/09/2023]
Abstract
OBJECTIVES The current study examined the relationship between preoperative anxiety and acute postoperative phantom limb pain (PLP), residual limb pain (RLP), and analgesic medication use in a sample of persons undergoing lower limb amputation. MATERIALS AND METHODS Participants included 69 adults admitted to a large level 1 trauma hospital for lower limb amputation. Participants' average pain and anxiety during the previous week were assessed before amputation surgery. RLP, PLP, and analgesic medication use were measured on each of the 5 days following amputation surgery. RESULTS Results of partial-order correlations indicated that greater preoperative anxiety was significantly associated with greater ratings of average PLP for each of the 5 days following amputation surgery, after controlling for preoperative pain ratings and daily postoperative analgesic medication use. Partial correlation values ranged from 0.30 to 0.62, indicating medium to large effects. Preoperative anxiety was also significantly associated with ratings of average RLP only on postoperative day 1, after controlling for preoperative pain ratings and daily postoperative analgesic medication use (r=0.34, P<0.05). Correlations between preoperative anxiety and daily postoperative analgesic medication dose became nonsignificant when controlling for preamputation and postamputation pain ratings. DISCUSSION These findings suggest that anxiety may be a risk factor for acute postamputation PLP and RLP, and indicate that further research to examine these associations is warranted. If replicated, the findings would support research to examine the extent to which modifying preoperative anxiety yields a reduction in postoperative acute PLP and RLP.
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Geertzen J, van der Linde H, Rosenbrand K, Conradi M, Deckers J, Koning J, Rietman HS, van der Schaaf D, van der Ploeg R, Schapendonk J, Schrier E, Smit Duijzentkunst R, Spruit-van Eijk M, Versteegen G, Voesten H. Dutch evidence-based guidelines for amputation and prosthetics of the lower extremity: Amputation surgery and postoperative management. Part 1. Prosthet Orthot Int 2015; 39:351-60. [PMID: 25060392 DOI: 10.1177/0309364614541460] [Citation(s) in RCA: 21] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/26/2014] [Accepted: 06/02/2014] [Indexed: 02/03/2023]
Abstract
BACKGROUND Surgeons still use a range of criteria to determine whether amputation is indicated. In addition, there is considerable debate regarding immediate postoperative management, especially concerning the use of 'immediate/delayed fitting' versus conservative elastic bandaging. OBJECTIVES To produce an evidence-based guideline for the amputation and prosthetics of the lower extremities. This guideline provides recommendations in support of daily practice and is based on the results of scientific research and further discussions focussed on establishing good medical practice. Part 1 focuses on amputation surgery and postoperative management. STUDY DESIGN Systematic literature design. METHODS Literature search in five databases. Quality assessment on the basis of evidence-based guideline development. RESULTS An evidence-based multidisciplinary guideline on amputation and prosthetics of the lower extremity. CONCLUSION The best care (in general) for patients undergoing amputation of a lower extremity is presented and discussed. This part of the guideline provides recommendations for diagnosis, referral, assessment, and undergoing amputation of a lower extremity and can be used to provide patient information. CLINICAL RELEVANCE This guideline provides recommendations in support of daily practice and is based on the results of scientific research and further discussions focussed on establishing good medical practice.
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Affiliation(s)
- Jan Geertzen
- Department of Rehabilitation Medicine, University Medical Center Groningen, University of Groningen, Groningen, The Netherlands
| | | | | | | | - Jos Deckers
- Royal Dutch Society for Physical Therapies, Utrecht, The Netherlands
| | - Jan Koning
- Dutch Society for Surgery, Utrecht, The Netherlands
| | | | | | | | | | - Ernst Schrier
- Netherlands Institute of Psychologists, Utrecht, The Netherlands
| | - Rob Smit Duijzentkunst
- Netherlands Association for Occupational and Industrial Medicine, Utrecht, The Netherlands
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A retrospective trial comparing the effects of different anesthetic techniques on phantom pain after lower limb amputation. Curr Ther Res Clin Exp 2014; 72:127-37. [PMID: 24648582 DOI: 10.1016/j.curtheres.2011.06.001] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 06/02/2011] [Indexed: 11/21/2022] Open
Abstract
BACKGROUND Pain and other sensations from an amputated or absent limb, called phantom pain and phantom sensations, are well-known phenomena. OBJECTIVE The aim of this retrospective study was to evaluate the effects of anesthetic techniques on phantom pain, phantom sensations, and stump pain after lower limb amputation. METHODS Ninety-two patients with American Society of Anesthesiologists physical status I to III were analyzed for 1 to 24 months after lower limb amputation in this retrospective study. Patients received general, spinal, or epidural anesthesia or peripheral nerve block for their amputations. Standardized questions were used to assess phantom limb pain, phantom sensation, and stump pain postoperatively. Pain intensity was assessed on a numeric rating scale (NRS) of 0 to 10. Patients' medical histories were determined from hospital records. RESULTS Patients who received epidural anesthesia and peripheral nerve block perceived significantly less pain in the week after surgery compared with patients who received general anesthesia and spinal anesthesia (NRS [SD] values, 2.68 [1.0] and 2.70 [1.0], respectively). After approximately 14 to 17 months, there was no difference in phantom limb pain, phantom sensation, or stump pain among the anesthetic techniques for amputation. CONCLUSIONS In patients undergoing lower limb amputation, performing epidural anesthesia or peripheral nerve block, instead of general anesthesia or spinal anesthesia, might attenuate phantom and stump pain in the first week after operation. Anesthetic technique might not have an effect on phantom limb pain, phantom sensation, or stump pain at 14 to 17 months after lower limb amputation.
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Chaparro LE, Smith SA, Moore RA, Wiffen PJ, Gilron I. Pharmacotherapy for the prevention of chronic pain after surgery in adults. Cochrane Database Syst Rev 2013; 2013:CD008307. [PMID: 23881791 PMCID: PMC6481826 DOI: 10.1002/14651858.cd008307.pub2] [Citation(s) in RCA: 98] [Impact Index Per Article: 8.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/21/2022]
Abstract
BACKGROUND Chronic pain can often occur after surgery, substantially impairing patients' health and quality of life. It is caused by complex mechanisms that are not yet well understood. The predictable nature of most surgical procedures has allowed for the conduct of randomized controlled trials of pharmacological interventions aimed at preventing chronic postsurgical pain. OBJECTIVES The primary objective was to evaluate the efficacy of systemic drugs for the prevention of chronic pain after surgery by examining the proportion of patients reporting pain three months or more after surgery. The secondary objective was to evaluate the safety of drugs administered for the prevention of chronic pain after surgery. SEARCH METHODS We identified randomized controlled trials (RCTs) of various systemically administered drugs for the prevention of chronic pain after surgery from CENTRAL, MEDLINE, EMBASE and handsearches of other reviews and trial registries. The most recent search was performed on 17 July 2013. SELECTION CRITERIA Included studies were double-blind, placebo-controlled, randomized trials involving adults and evaluating one or more drugs administered systemically before, during or after surgery, or both, which measured pain three months or more after surgery. DATA COLLECTION AND ANALYSIS Data collected from each study included the study drug name, dose, route, timing and duration of dosing; surgical procedure; proportion of patients reporting any pain three months or more after surgery, reporting at least 4/10 or moderate to severe pain three months or more after surgery; and proportion of participants dropping out of the study due to treatment-emergent adverse effects. MAIN RESULTS We identified 40 RCTs of various pharmacological interventions including intravenous ketamine (14 RCTs), oral gabapentin (10 RCTs), oral pregabalin (5 RCTs), non-steroidal anti-inflammatories (3 RCTs), intravenous steroids (3 RCTs), oral N-methyl-D-aspartate (NMDA) blockers (3 RCTs), oral mexiletine (2 RCTs), intravenous fentanyl (1 RCT), intravenous lidocaine (1 RCT), oral venlafaxine (1 RCT) and inhaled nitrous oxide (1 RCT). Meta-analysis suggested a modest but statistically significant reduction in the incidence of chronic pain after surgery following treatment with ketamine but not gabapentin or pregabalin. Results with ketamine should be viewed with caution since most of the included trials were small (that is < 100 participants per treatment arm), which could lead to the overestimation of treatment effect. AUTHORS' CONCLUSIONS Additional evidence from better, well designed, large-scale trials is needed in order to more rigorously evaluate pharmacological interventions for the prevention of chronic pain after surgery. Furthermore, available evidence does not support the efficacy of gabapentin, pregabalin, non-steroidal anti-inflammatories, intravenous steroids, oral NMDA blockers, oral mexiletine, intravenous fentanyl, intravenous lidocaine, oral venlafaxine or inhaled nitrous oxide for the prevention of chronic postoperative pain.
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Abstract
Postamputation pain (PAP) is highly prevalent after limb amputation but remains an extremely challenging pain condition to treat. A large part of its intractability stems from the myriad pathophysiological mechanisms. A state-of-art understanding of the pathophysiologic basis underlying postamputation phenomena can be broadly categorized in terms of supraspinal, spinal, and peripheral mechanisms. Supraspinal mechanisms involve somatosensory cortical reorganization of the area representing the deafferentated limb and are predominant in phantom limb pain and phantom sensations. Spinal reorganization in the dorsal horn occurs after deafferentataion from a peripheral nerve injury. Peripherally, axonal nerve damage initiates inflammation, regenerative sprouting, and increased "ectopic" afferent input which is thought by many to be the predominant mechanism involved in residual limb pain or neuroma pain, but may also contribute to phantom phenomena. To optimize treatment outcomes, therapy should be individually tailored and mechanism based. Treatment modalities include injection therapy, pharmacotherapy, complementary and alternative therapy, surgical therapy, and interventions aimed at prevention. Unfortunately, there is a lack of high quality clinical trials to support most of these treatments. Most of the randomized controlled trials in PAP have evaluated medications, with a trend for short-term Efficacy noted for ketamine and opioids. Evidence for peripheral injection therapy with botulinum toxin and pulsed radiofrequency for residual limb pain is limited to very small trials and case series. Mirror therapy is a safe and cost-effective alternative treatment modality for PAP. Neuromodulation using implanted motor cortex stimulation has shown a trend toward effectiveness for refractory phantom limb pain, though the evidence is largely anecdotal. Studies that aim to prevent PA P using epidural and perineural catheters have yielded inconsistent results, though there may be some benefit for epidural prevention when the infusions are started more than 24 hours preoperatively and compared with nonoptimized alternatives. Further investigation into the mechanisms responsible for and the factors associated with the development of PAP is needed to provide an evidence-based foundation to guide current and future treatment approaches.
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Affiliation(s)
- Eugene Hsu
- Johns Hopkins School of Medicine, Baltimore, MD, USA
| | - Steven P Cohen
- Johns Hopkins School of Medicine and Uniformed Services, University of the Health Sciences, Bethesda, MD, USA
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Abstract
Background Surgical injury can frequently lead to chronic pain. Despite the obvious importance of this problem, the first publications on chronic pain after surgery as a general topic appeared only a decade ago. This study tests the hypothesis that chronic postsurgical pain was, and still is, represented insufficiently. Methods We analyzed the presentation of this topic in journal articles covered by PubMed and in surgical textbooks. The following signs of insufficient representation in journal articles were used: (1) the lack of journal editorials on chronic pain after surgery, (2) the lack of journal articles with titles clearly indicating that they are devoted to chronic postsurgical pain, and (3) the insufficient representation of chronic postsurgical pain in the top surgical journals. Results It was demonstrated that insufficient representation of this topic existed in 1981–2000, especially in surgical journals and textbooks. Interest in this topic began to increase, however, mostly regarding one specific surgery: herniorrhaphy. It is important that the change in the attitude toward chronic postsurgical pain spreads to other groups of surgeries. Conclusion Chronic postsurgical pain is still a neglected topic, except for pain after herniorrhaphy. The change in the attitude toward chronic postsurgical pain is the important first step in the approach to this problem.
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Affiliation(s)
- Igor Kissin
- Department of Anesthesiology, Perioperative and Pain Medicine, Brigham and Women's Hospital, Harvard Medical School, Boston, MA, USA
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Andreae MH, Andreae DA. Local anaesthetics and regional anaesthesia for preventing chronic pain after surgery. Cochrane Database Syst Rev 2012; 10:CD007105. [PMID: 23076930 PMCID: PMC4004344 DOI: 10.1002/14651858.cd007105.pub2] [Citation(s) in RCA: 74] [Impact Index Per Article: 6.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/23/2022]
Abstract
BACKGROUND Regional anaesthesia may reduce the rate of persistent (chronic) pain after surgery, a frequent and debilitating condition. OBJECTIVES To compare local anaesthetics and regional anaesthesia versus conventional analgesia for the prevention of persistent pain six or 12 months after surgery. SEARCH METHODS We searched the Cochrane Central Register of Controlled Trials (CENTRAL) (The Cochrane Library 2012, Issue 4), PubMed (1966 to April 2012), EMBASE (1966 to May 2012) and CINAHL (1966 to May 2012) without any language restriction. We used a combination of free text search and controlled vocabulary search. The results were limited to randomized controlled clinical trials (RCTs). We conducted a handsearch in reference lists of included trials, review articles and conference abstracts. SELECTION CRITERIA We included RCTs comparing local anaesthetics or regional anaesthesia versus conventional analgesia with a pain outcome at six or 12 months after surgery. DATA COLLECTION AND ANALYSIS Two authors independently assessed trial quality and extracted data, including information on adverse events. We contacted study authors for additional information. Results are presented as pooled odds ratios (OR) with 95% confidence intervals (CI), based on random-effects models (inverse variance method). We grouped studies according to surgical interventions. We employed the Chi(2) test and calculated the I(2) statistic to investigate study heterogeneity. MAIN RESULTS We identified 23 RCTs studying local anaesthetics or regional anaesthesia for the prevention of persistent (chronic) pain after surgery. Data from a total of 1090 patients with outcomes at six months and of 441 patients with outcomes at 12 months were presented. No study included children. We pooled data from 250 participants after thoracotomy, with outcomes at six months. Data favoured regional anaesthesia for the prevention of chronic pain at six months after thoracotomy with an OR of 0.33 (95% CI 0.20 to 0.56). We pooled two studies on paravertebral block for breast cancer surgery; the pooled data of 89 participants with outcomes at five to six months favoured paravertebral block with an OR of 0.37 (95% CI 0.14 to 0.94).The methodological quality of the included studies was intermediate. Adverse effects were not studied systematically and were reported sparsely. Clinical heterogeneity, attrition and sparse outcome data hampered the assessment of effects, especially at 12 months. AUTHORS' CONCLUSIONS Epidural anaesthesia may reduce the risk of developing chronic pain after thoracotomy in about one patient out of every four patients treated. Paravertebral block may reduce the risk of chronic pain after breast cancer surgery in about one out of every five women treated. Our conclusions are significantly weakened by performance bias, shortcomings in allocation concealment, considerable attrition and incomplete outcome data. We caution that our evidence synthesis is based on only a few, small studies. More studies with high methodological quality, addressing various types of surgery and different age groups, including children, are needed.
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Affiliation(s)
- Michael H Andreae
- Department of Anesthesiology, Montefiore Medical Center, Albert Einstein College of Medicine, New York, NY,
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McGreevy K, Bottros MM, Raja SN. Preventing Chronic Pain following Acute Pain: Risk Factors, Preventive Strategies, and their Efficacy. ACTA ACUST UNITED AC 2012; 5:365-372. [PMID: 22102847 DOI: 10.1016/j.eujps.2011.08.013] [Citation(s) in RCA: 138] [Impact Index Per Article: 11.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Abstract
Chronic pain is the leading cause of disability in the United States. The transition from acute to persistent pain is thought to arise from maladaptive neuroplastic mechanisms involving three intertwined processes, peripheral sensitization, central sensitization, and descending modulation. Strategies aimed at preventing persistent pain may target such processes. Models for studying preventive strategies include persistent post-surgical pain (PPP), persistent post-trauma pain (PTP) and post-herpetic neuralgia (PHN). Such entities allow a more defined acute onset of tissue injury after which study of the long-term effects is more easily examined. In this review, we examine the pathophysiology, epidemiology, risk factors, and treatment strategies for the prevention of chronic pain using these models. Both pharmacological and interventional approaches are described, as well as a discussion of preventive strategies on the horizon.
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Affiliation(s)
- Kai McGreevy
- Department of Anesthesiology and Critical Care Medicine, Johns Hopkins University, School of Medicine, Baltimore, MD, USA
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Phantom Pain Syndromes. Pain Manag 2011. [DOI: 10.1016/b978-1-4377-0721-2.00032-5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/23/2022] Open
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The use of prolonged peripheral neural blockade after lower extremity amputation: the effect on symptoms associated with phantom limb syndrome. Anesth Analg 2010; 111:1308-15. [PMID: 20881281 DOI: 10.1213/ane.0b013e3181f4e848] [Citation(s) in RCA: 103] [Impact Index Per Article: 7.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Abstract
BACKGROUND Phantom limb syndrome (PLS) is common after limb amputations, involving up to 90% of amputees. Although many different therapies have been evaluated, none has been found to be highly effective. Therefore, we evaluated the efficacy of a prolonged perineural infusion of a high concentration of local anesthetic solution in preventing PLS. METHODS A perineural catheter was placed immediately before or during surgery in 71 patients undergoing lower extremity amputation. A continuous infusion of 0.5% ropivacaine was started intraoperatively at 5 mL/h using an elastomeric (nonelectronic) pump, and continued for 4 to 83 days after surgery. PLS was evaluated on the first postoperative day and then 1, 2, 3, and 4 weeks, and 3, 6, 9, and 12 months after surgery. To evaluate the presence and severity of PLS while the patient was receiving the ropivacaine infusion, it was discontinued for 6 to 12 hours before each assessment period (i.e., until the sensation in the extremity returned). The severity of phantom limb and stump pain was assessed using a 5-point verbal rating scale (VRS), with 0 = no pain to 4 = intolerable pain, and "phantom" sensations were recorded as present or absent. If the VRS score was >1 or significant phantom sensations were present, the ropivacaine infusion was immediately restarted at 5 mL/h. If the VRS score remained at 0 to 1 and the patient had not experienced phantom sensations for 48 hours, the infusion was permanently discontinued and the catheter was removed. RESULTS Median duration of the local anesthetic infusion was 30 days (95% confidence interval, 25-30 days). On postoperative day 1, 73% of the patients complained of severe-to-intolerable pain (visual analog scale >2). However, the incidence of severe-to-intolerable phantom limb pain was only 3% at the end of the 12-month evaluation period. At the end of the 12-month period, the percentage of patients with VRS pain scores were 0 = 84%, 1 = 10%, 2 = 3%, 3 = 3%, and 4 = none. However, phantom limb sensations were present in 39% of patients at the end of the 12-month evaluation period. All patients were able to manage the elastomeric catheter infusion system at home. CONCLUSION Use of a prolonged postoperative perineural infusion of ropivacaine 0.5% seems to be an effective therapy for the treatment of phantom limb pain and sensations after lower extremity amputation.
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Abstract
The development of chronic pain after surgery is not an uncommon event. Despite increased attention devoted to this topic in the recent medical literature, little is known about the underlying mechanisms, natural history, and response to therapy of each syndrome. Central nervous system plasticity that occurs in response to tissue injury may contribute to the development of persistent postsurgical pain. As evidence continues to accumulate concerning the role of central sensitization in the prolongation of postoperative pain, many researchers have focused on methods to prevent central neuroplastic changes from occurring through the use of preemptive or preventative analgesic techniques. Effective preventative analgesic techniques may be useful in reducing not only acute pain but also chronic postsurgical pain and disability. This review examines the efficacy of using a variety of analgesic techniques aimed at preventing or reducing chronic pain after surgery. Specific chronic postsurgical pain syndromes evaluated include complex regional pain syndrome, phantom limb pain, chronic donor site pain, post-thoracotomy pain syndrome, and postmastectomy pain syndrome.
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Affiliation(s)
- Scott S Reuben
- Department of Anesthesiology, Baystate Medical Center, Springfield, MA 01199, USA.
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Engelhardt L, Schaser KD, Fritzsche T, Birnbaum J, Spies CD, Volk T. Intraneural catheter placement for post-operative pain therapy in an amputee. Acta Anaesthesiol Scand 2007; 51:131. [PMID: 17229234 DOI: 10.1111/j.1399-6576.2006.01194.x] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
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Lavand'homme PM, Eisenach JC. Perioperative administration of the α2-adrenoceptor agonist clonidine at the site of nerve injury reduces the development of mechanical hypersensitivity and modulates local cytokine expression. Pain 2003; 105:247-54. [PMID: 14499442 DOI: 10.1016/s0304-3959(03)00221-5] [Citation(s) in RCA: 98] [Impact Index Per Article: 4.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
The development of chronic pain after surgery is not rare. Nerve injury from complete or partial nerve section during surgery leads to macrophage recruitment and release of pro-inflammatory cytokines, leading in turn to sensitization. Macrophages also express alpha2-adrenoceptors, and we previously demonstrated a prolonged reduction in hypersensitivity following peri-neural injection of the alpha2-adrenoceptor agonist, clonidine, in rats with chronic nerve injury. The current study tested whether peri-neural clonidine at the time of injury could also prevent development of hypersensitivity. Rats underwent partial ligation of one sciatic nerve, and peri-neural saline, clonidine or a combination of clonidine and the alpha2A-adrenceptor-preferring antagonist, BRL44408, were administered before wound closure and, in some animals, also 24 and 48 h later. The single clonidine injection reduced hypersensitivity for only 5 h, whereas repeated injection for three days reduced hypersensitivity for 28 days. Peri-neural clonidine reduced the increase in tissue content of the proinflammatory cytokines IL-1beta and particularly TNFalpha in sciatic nerve, DRG and spinal cord while increasing concentrations of the anti-inflammatory cytokine TGF-beta1. Clonidine's effects on behavior and TNFalpha content were blocked by BRL44408. We conclude that peri-neural administration of clonidine at the site and time of injury reduces the degree of hypersensitivity in part by altering the balance of pro- and anti-inflammatory cytokines through activation of alpha2A-adrenoceptors. These results support testing of whether clonidine, as an adjuvant in continuous peripheral nerve blocks in settings of known major nerve injury, such as limb amputation, might prevent the development of chronic pain.
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Affiliation(s)
- P M Lavand'homme
- Department of Anesthesiology and Pain Clinic, St Luc Hospital Medical School, Université Catholique de Louvain, Brussels, Belgium
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Abstract
BACKGROUND Advances in oncological practice have reduced the number of major amputations performed for soft-tissue sarcoma, but this remains a valuable, if infrequent, option for both curative and palliative indications. METHODS A review of patients and case-notes was carried out from the prospective sarcoma database at the Royal Marsden Hospital. RESULTS Over a 10-year interval, 40 major amputations (18 forequarter, 17 hindquarter and five through hip) were performed, predominantly for disease recurring after previous limb-conserving surgery (31 of 40). A wide variety of soft-tissue sarcoma subtypes was seen; they were often large (more than 10 cm; 18 of 40) or multifocal (six), usually high grade (25), and frequently proximal or involving neurovascular structures such that limb salvage was precluded. Median range age of the patients was 59 (17-87) years. The operative 30-day mortality rate was zero. Hospital stay was a median of 10.5 days for forequarter amputation, and 19 days for hindquarter and through-hip amputation. Local recurrence occurred in ten patients, six of whom had concurrent distant metastases. Twenty-seven patients were alive (20 disease free) at a median follow-up of 12 months, nine of whom were alive without evidence of disease beyond 2 years. Ten patients died after a median of 7.5 months; three survived more than 2 years. CONCLUSION Major amputation is a useful procedure in carefully selected patients with soft-tissue sarcoma.
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Affiliation(s)
- M A Clark
- Melanoma and Sarcoma Unit, Royal Marsden Hospital, Fulham Road, Chelsea, London SW3 6JJ, UK
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